Overview
History of present illness (HPI) and Admitting Diagnosis | 8 ptsProficientExplains 1) HPI and 2) admitting pathophysiology in detail with clear and accurate and in-depth understanding of chief complaint. 3) Evidence-based rationales clearly and accurately support the HPI. |
Pathophysiology of past medical/surgical/social histories | 10 ptsProficientIncludes 1) all past medical, surgical, and social history detailed with 2) full explanation of pathophysiology for each diagnosis. 3) Thoroughly describes potential complications for each diagnosis and the indications for surgery. 4) Clearly and accurately relates the client's past history and current signs/symptoms with evidence-based citations. |
6 ptsProficient1) Clearly and accurately describes socioeconomic and psychosocial background in detail 2) with evidence-based citations to support social determinants of health. 3) Identifies at least 3 or more psychosocial concerns with interventions/ recommendations. |
Erikson’s Developmental Stages | 4 ptsProficient1) Identifies and 2) defines correct stage 3) with examples of meeting/not meeting tasks 4) supported by evidenced-based citations. |
Teaching Assessment & Client Education | 6 ptsProficient1) Clearly and accurately identifies areas of instructional needs, 2) learning preference, and 3) learning barriers. 4) Provides clear and concise client education related to their condition that will aid in health promotion, health maintenance and self-care activities. 5) Client education is supported by evidence-based practice. |
Interprofessional Consults and Multidisciplinary Plan | 6 ptsProficient1) Lists at least 3 appropriate collaborative issues/concerns. 2) Identifies 3 interdisciplinary consults to support patient well-being. 3) Evidence- based rationales demonstrate clear and accurate understanding of consults and interventions. |
Discharge Planning | 6 ptsProficientClearly and accurately 1) describes issues/concerns related to discharge planning 2) with evidence-based rationales. |
Labs | 10 ptsProficient1) Clearly and accurately identifies admission and current pertinent laboratory tests with applicable indications, 2) addresses abnormal values, and 3) recognizes trends related to a client’s disease process 4) with evidence-based rationales. |
Diagnostics/procedures | 10 ptsProficient1) Clearly and accurately describes the client’s diagnostic criteria and indications 2) with evidence- based rationales that clearly support the chief complaint and presenting signs/symptoms. |
Medications | 16 ptsProficientClearly and accurately 1) identifies all components of the medication list, including name, class, route, dose, frequency, mechanism of action, applicable indication(s), side and adverse effects, interactions, and nursing considerations relevant to the client’s current health condition, 2) with evidence-based citations. |
Assessment & Review of Systems | 14 ptsProficient1) Documents thorough Head-to-Toe physical assessment with relevant information to the patient/client as performed by the student. 2) Utilizes an organized format and appropriate terms to describe both normal and abnormal assessment findings. |
Recognition of cues (Assessment) | 16 ptsProficientIdentifies all imperative cues taken from the environment, patient assessment/observation, medical record, other resources, time pressures, task complexity, and cultural considerations. Minimum of 15 cues required. |
Analysis of cues (Analysis) | 16 ptsProficient1) Links and clusters recognized cues to the client's clinical presentation. Accurately 2) establishes prioritized client needs based off the patient’s clinical presentation. Clearly and accurately clusters cues to establish probable patient needs, concerns, or problems. |
Prioritization of hypotheses (Analyze) | 16 ptsProficient1) Establishes 4 priorities of care based on the client's health problems (i.e., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values). 2) The clinical decision is clear, accurate, and presents correlation from the recognized cues. 3) Identifies the framework used to identify priority order (ABCs, Maslow, safety, acute v chronic, unstable v stable, urgent v non-urgent). |
Generation of solutions (Planning) | 24 ptsProficientClearly and accurately 1) establishes one expected outcome to address each hypothesis that can be achieved with nursing assistance to ensure a client’s needs are met. Outcomes are specific, measurable, realistically attainable, and appropriately timed. 2) Identifies 4 solutions for each outcome supported by evidence-based practice. Clearly and accurately identifies at least 16 solutions that are independent nursing interventions supported by scientific rationale and evidence-based practice. |
Take actions (Implementation) | 8 ptsProficient1) Implements appropriate interventions in priority order based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client's health. 2) Nursing actions are always aimed at the expected outcomes and directed at the stated health deviation based on the nursing assessment and Erikson’s stages of development. |
Evaluate Outcomes (Evaluation) | 16 ptsProficientClearly and accurately 1) identifies criteria for evaluation, effectiveness of interventions, and measurement of goal completion. 2) Evaluation is clearly and accurately linked to the generated solutions and overall plan of care. 3) Modifies, revises, and recommends alternative solutions with evidence-based citations as applicable. |
General Organization | 8 ptsProficient1) Clear and accurate APA format. 2) Concisely appropriate citations and references. 3) No spelling or grammar errors. |